The lives of the pregnant women are in the hands of the mother -How to daignose placenta accretion earliest

The lives of the pregnant women are in the hands of the mother -How to diagnose placenta accretion earliest : Diagnosed early placenta Recollections on cobra bite : Dealing with placenta accreta.

Classification of Placenta accreta : These are  basically of two types of accretion :-A) Focal and B) Total-(when all the cotyledons have invaded the myometrium). The prevalence of combined focal & total Abruptio  Placentae in genl Obstet population is  about 1 : 500 in  unscarred uterus . But such  prevalence rises sharply in  cases with scarred uterus. For instance , in post CS cases the rate of accretion will be  around 3%,(after first CS),  11%(after two CS),  40% after third seectin,and alarmingly (dreadfully) the prevalence of accretion will be as high as 67% after 5^th CS!!! .Placental accretion is a nightmare for third stage!! But how best to handle it-? I mean the steps which may be avoided to provoke sudden severe PPH as an attempt is made to remove  the placenta in piece meal ? If we can diagnose antenatally then we can arrange to deliver at tertiary care center.   How to diagnose prenatally??  Ans:- In general ,  most women in India too undergoes three USG or more in entire preg period , many undergoes 7-10 times USG  depending on risk factor/s. At anomaly scan (18-20 weeks of gestation or at growth scan ( 28-32 weeks) there will be evidences of accretion if sonologist is dedicated one . This(placental accretion)  can be easily picked up if sonologist concerned is not overburdened as commonly happens. Regrettably  even today  there are  disparity between the no of cases in a  locality who warrant sonological evaluation and no of sonologist.

 The role of sonologist : It is they can save thousands of material lives out of Placental accretion!!! But sonologist can warn us even by 2 D & CD though 3-D will be more informative and easy to pick up particularly they  will offer an accurate  diagnosis at least in growth scan if not in anomaly scan.  MRI , a better modality is  if often unnecessary.   However if  such an diagnoses would have been done in your case at about 32 weeks then  I would have recommended to refer her to higher center.

                                            

What to do in diagnosed cases??Ans: There are people  who perform Caesarean hysterctomy  with placenta in situ-soon after delivery of baby if preop diag was certain. They very rightly don’t try to remove the placenta by piecemeal. But there is more people who thinks “let’s try to see if pl  can be separated ignoring the previous report of sonologist. In the process i.e. to remove  the placenta there is usually torrential bleeding . They fall in trap with torrential bleeding .In such a situation , primi in particular , all  four vessels feeding the vesseks may be tied with B-Lunch type of box suture. Or UAE may be considetd well ahead if pre op  diag was certain. Urosurgron may be preop called  at OT before putting incision  if there is MRI/ sonological  evidence of pl invasion to bladder wall . Several Square stitches (a great modification of B-Lynch compression stitches) may help but then even some portions of pl will remain in and sepsis may ensue. Some have recommended conservative approach leaving aside the whole placenta or pieces of pl allowing the nature to expel of its own.  Earlier people  used to inj MTX in cord which is left aside but this not recommended right now as villi are dead.  ,By doing so torrential bleedings avoided

Take home message: The prevalence of placental morbid adhesions on the rise globally and those who are working at remote arrases without any diag by USG antenatally fall in trap after the birth of seeming normal vaginal delivery, Often Whole blood and compete anesthetist are unavailable at Block level ,It is said an attempt to spear the adherent pl can lead to massive hemorrhage amounting to 3Lit top even 5L. So my appeal if placenta does not come out easily it will be prudent to send her to tertiary care center where hyercterectomy may be contemplated undwee PCV/ whole Bl transfusion. Inotrops may be useful during  trabsport, If a nurse agrees to accompany she*nurse ) can change the RL on the way..There many theories why accreting occurs in primi where there is no previous damage to endometrium. Researchers  claim that in such cases (taking it granted there was no tubercular syechaE0 , the cause of accretion as suggested by thecae 1) Primary endometrial defect or 2) hay[err invasions of cite due to EGFR, VRGF. , Nowadays with incising prevalence of IVF, affianced aged of mother , more cases Essn HTN (as was this case), smoking, submucous myoma are the initiating factors of accretion in Primosa dedicated sonologist can almost certainly pick up Accretion early by 1) loss of retro pl son lucent  zone, 2) Thinning

  accreta can be relatively safely delivered at tertiary center..